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General NPI Number Information
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NPI Number | 1093108326
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Entity Type | Organization
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Legal Business Name | SUNSHINE STATE PEDIATRICS
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Dates
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Enumeration Date | 03/11/2015
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Last Update Date | 03/11/2015
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Provider Practice Location Address
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Address Line | 16800 NW 2ND AVENUE SUITE 307
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City | NORTH MIAMI BEACH
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State | FL
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Zip | 33169
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Country | US
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Telephone | 305-655-2340
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Fax | 305-770-9382
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Provider Business Mailing Address
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Address Line | 16800 NW 2ND AVE SUITE 307
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City | NORTH MIAMI BEACH
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State | FL
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Zip | 33169-5549
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Country | US
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Telephone | 305-655-2340
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Fax | 305-770-9382
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Authorized Official
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Title or Position | OWNER
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Name | RONALD GRAY
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Credential | M.D.
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Telephone | 305-655-2340
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | ME58963
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License Number State | FL
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